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Thursday, August 8, 2013

First Call

It's my first overnight call in the hospital. It's 7pm and I've been at work for 13 hours. There are 16 more hours to go. My arms are halfway through the portholes of an isolette and my hands are cradling the tiny hand of one of my patients who needs a blood culture and screening labs. I am shush-shush-shush-ing the baby as I choose my spot, swab it with alcohol, and pierce the skin quickly and definitively, trying to cause as little pain as possible. My pager phone is buzzing and beeping against my hip, the nurses are mobilizing, talking, helping each other do all the things this sick baby needs done, but for the moment it is just me and this hand and the artery that is hidden a few milimeters beneath the skin. After a few adjustments of the needle, the red arterial blood flashes into the needle, travels up the tubing, and begins to fill the syringe. My shoulders start to unknit themselves and I take what feels like my first breath in a while. Thirty seconds pass as the syringe slowly fills. There's nothing else I can do for the moment but stand here. I haven't stopped moving and doing and thinking and worrying for the past 13 hours, so this feels like a break. The baby is chewing on his pacifier, looking around for the source of the sting, and our eyes meet for a moment before the blood hits the 2cc mark and I retract the needle into its hub. "Thanks, little man," I whisper to him softly, grateful to have gotten the blood, grateful that I don't have to cause him more pain with a second stick, grateful that I don't have to call the fellow to come and help me, grateful for the couple of breaths I took and whatever small thing passed between us. In the time it took for the stick -- no more than three or four minutes -- four new pages have come through and I am needed in four places at once and I don't breathe again until well after midnight.

* * * * *

The most recent change in the ACGME medical training rules happened when I was a fourth year medical student. At the time, all the protest over the limitation of interns to 16 hour shifts seemed silly to me. How could anyone protest a seemingly more humane schedule? What was the big deal? Then I got to intern year and began to understand the widespread dissent. The day-float, night-float system featured constant signout -- on long call days, I would spend 2-3 hours of my day signing out. I worked 13, 14, 15 hours six days a week, enduring the pain of long separations from my child, often staying up late working on notes and discharge summaries -- and still there was never enough time to see patients, with rounds and conferences and notes and sign out and the endless to-do lists. Most disturbingly, I felt like I wasn't learning as much as I expected. Admitting a patient was more a matter of administrative work. There was never the opportunity to travel with the patient through the process of diagnosis and treatment. At best I would put in the initial orders, then sign the patient out to the night person. Nights were a little better, with more opportunity to actually see patients and think about them, but six consecutive 15 hour days left me feeling exhausted and was hugely disruptive to my family. I began to feel resentful all the time. Worse, I began to forget why I went into medicine in the first place.

As second year neared, I was filled with both apprehension (would I actually be able to function for 30 hours in a row?) and excitement for the switch to a Q4 overnight call schedule. What was I looking forward to? The time to actually see patients. The chance to spend at least one out of every four afternoons with my daughter. The chance to admit and then follow my own patients instead of picking up overnight admissions and shuffling patients when one or another team member switched to nights. The sense of mastery that would come with being able to manage patients by myself overnight. I was hoping to fall in love with medicine again.

* * * * *

It's 3:30am and even though I should be trying to catch a little sleep during a lull, I am worrying about sodium. One of my patients has a sodium of 129. It's not low enough to panic, but it's not normal. It's not low enough to call the fellow who has probably already gone to lie down but it's low enough to make me lie awake in the dark, wondering if I should intervene or not intervene, wondering if I should call the fellow or not, feeling like this is the kind of problem I should be able to solve on my own. I get up and turn on the light in the small call room and set about reading about neonatal hyponatremia, which confirms that the baby is not in danger. I could go down on his fluids, but he is losing more than the typical amount of fluid through his unrepaired myeloschesis and there has been concern all day for poor urine output. On the other hand, it's hard to imagine that he is fluid down with a sodium of 129. I go around and around in my head, weighing the sodium level against the risk of insensible fluid loss. I decide to recheck a level in the morning and leave the fluids where they are. It's a small decision but it keeps me tossing and turning for the interrupted hour and a half I have to rest before the morning work starts. When the BMP pops up at 6am, my heart catches in my throat for a moment. What if his sodium is 121? It's 130. On rounds later in the morning, we decide to leave the fluids where they are. For the team it's a small decision -- no one even notices -- but for me it's the end of an arc of learning: how to tolerate the anxiety of uncertainty, how to make a clinical decision when there are no protocols to follow, how to think through a problem and come up with a safe solution. If I had been there with a senior resident, I would have just asked them and they would have changed the fluids or not changed the fluids. I would have slept better. But I would have been no farther along in my ability to take care of patients independently.

Post-call rounding is a whole new experience. I know all the patients and what has happened to them over the past 24 hours. I was there yesterday when decisions were made on rounds and I watched these decisions play out. I have listened to these lungs, stared at these monitors, felt these bellies all night long. I am the one who was here. For the first time, none of the patients on rounds are new to me -- they are all mine. I have the opportunity to get feedback from the attending about my overnight decisions, learning that will stick with me forever. Even though I am exhausted, it is exhilarating. I go home, sleep for a few hours in the afternoon, then have the incredible treat of going to pick my daughter up at day care, something I could almost never do on the intern schedule. I have a normal evening with my family, full of all the quotidian details of dinner, bath, and bedtime that are my secret paradise. By the next morning, I am ready to dive back in.

* * * * *

The new duty hour rules were well intentioned, designed to keep patients safe and minimize the ill effects of sleep deprivation. But I think there needs to be some consideration of what may have been lost. The danger of sleep deprivation has to be balanced again the the burn-out associated with the relentless march of long days without the high-yield learning and sense of connection to patients bourne of the shared journey of an entire day. Being awake for 30 hours is hard. But feeling like a mediocre doctor while seeing my family for an hour a day for most days every month was much, much harder.

I'm curious to what other people think about the "new" (now not so new) duty hours.

20 comments:

You hit it right on the head. There are a number of issues with shift work and work hour limits on interns. The description of your patient is perfect - you followed his arc from beginning to end. Interns no longer have that continuity within an illness - admit a patient at 7 AM, follow them all day and all night, watch their illness process evolve. There are ways to make sign out more efficient (we recently implemented I-PASS in our hospital) but there's also the preparing you have to do in order to be able to sign out. On the administrative end, scheduling is a pain in the ass. I've been through this on the chief resident end and now as an associate program director. It was much easier to schedule the interns when everyone was q4. Now we have this weird night shift business (which we have had for seniors for a while on weekdays but don't need it on the weekends).

As an attending, there is no such thing as "work hour limits". You work when tired, stressed, and when you are being pulled in multiple different directions. You don't get a post-call day. If you're an ED attending or a hospitalist, you might get the luxury of shift work. The only thing that prepares you for working like that is actually working like that. Learning how to think when tired and hungry. Managing your time. Prioritizing. Those are all skills gained when taking 24 hour call. Is it safe? Who knows. I don't.

What I do know is that I have no idea how on June 30 of your intern year you can't take a 24 hour call, but as soon as July 1 hits you can. That is bonkers.

I totally agree with your last point -- what is different on July 1st of second year? If anything, you have less supervision -- no senior resident at your side -- and the patients are sicker. Intern year is now like the fifth year of medical school, only you learn less. They are even talking about extending training by a year, which I think would be an unfair burden on budding doctors who could complete their training effectively in the original time frame if they weren't hampered by the duty hours.

your story is my life to the tee right now. i did a double take when i read the first few lines because i could've written them. My current 2nd year schedule is q2 24hr calls in the NICU and they are exhausting, but i can say that i do feel more like a doctor thinking through the tough decisions for the patients that i now have more responsibility for. I also understand more about the nuances of medical care and more logical thought processes rather than blindly following an algorithm or orders from my senior or attending. it is however exhausting! Maybe a q4 schedule would be better. I do agree that intern schedule was lighter but so much was lost in constantly signing out our patients back and forth. And i still did not get to see my family as much. I still miss my family on this schedule but i guess that is something i will have to get used to. I guess there is no perfect way to do this... something will be lost either way, sleep with the 24-30 hr schedule, continuity of care with the shorter work hours. Some days i would pick one over the other, either way as doctors we have to go through the pain to gain this knowledge we are looking for.

Wow, mamadoc -- q2s! That is brutal! Hats off to you -- I hope you are eating A LOT of chocolate and finding ways to decompress. There is no perfect way -- there are sacrifices no matter how the eighty hours are divided out. Given that, it seems preferable to be becoming a better doctor in the process. Good luck with the teeny tinies!

I trained before all this, so i can't comment too much. Except, even then, I kind of liked being on call---not being away from my friends and loved ones---but the work part was nice. I got to make my own decisions, see them through, try again...focus on the patients rather than the admin b.s. that took up a lot of the daytime hours. I learned medicine on-call. Now, don't get me wrong...I don't MISS it...just glad I got a chance to have the experience.

I think the whole question of entitlement is an interesting one. What is a person entitled to? What should a person be forced to sacrifice? One's marriage? One's health? There must be a happy medium that facilitates high quality patient care while allowing physicians (both in training and beyond) to be healthy and free of resentment and crushing exhaustion all the time. But this "solution" is not the solution. Shift work is unrealistic in most fields of medicine and it would be better to find ways for people to fit their personal needs (aka sleep and some degree of connection to their family members) into clinical demands rather than arbitrarily deciding that ten hours between every "shift" is the right answer for everyone.

What an excellent and thoughtful post. I just finished my residency training in the Canadian system, where 24 hour call (+ 2 hour handover) is still the norm for residents (except in the province of Quebec, where they have a 16 hour maximum). So, I have only ever experienced 26 hour call. In fact, when I was a medical student, it was a 30 hour shift. I had three children during my medical training, so three pregnancies and three breastfeeding/pumping adventures during this time.

I completely relate to your comments about following your patients, and making decisions alone in the middle of the night, and how both of those things make you a better doctor. They also, ironically, do allow for more time with family on the post-call day. I have never experienced the sixteen hour shift so cannot comment on that experience, but, by description, I think I prefer the 26 hour. What I do wonder about is the long-term consequence of the stress and sleep deprivation associated with years of 26 hour shifts. There is certainly a short-term gain in terms of learning, but I suspect there are also long-term detrimental effects. For example, I may get to see my family post-call after a few hours sleep, but that time is often far from maximized, due to exhaustion, distraction (thoughts of the reading and preparing that needs to be done for the next shift, "at home work" such as bills, cleaning, planning, relationship maintenance), irritability, and a general sense of malaise that only the truly exhausted can understand. Over many years, I have struggled with the pervasive guilt that comes along with not "maximizing" my brief time at home, despite all my self-promises that I will do so. I also developed an autoimmune disorder, which I cannot help but wonder, could it be stress-related?

I guess what I am trying to say is that I believe that the 26 hour shift DID have a negative impact on my mental and physical health, and my life at home. What I am NOT saying is that sixteen hour sounds better. It doesn't. I am not sure what the solution is. Which is probably exactly why this is such a hotly debated issue.

On another note, I have recently started doing solo Emerg shifts, i.e. as the only doctor in house in a rural emergency department. And the terror and the high of being alone in the middle of the night has not ended with the end of residency! But my on-call experience as a resident has most certainly helped me to prepare for this.

I completely relate to everything you have written here! Kudos to you for your three-time pregnancy-in-medical-training accomplishment! I too struggle constantly with the sense of guilt at not maximizing my time at home. I have to choose between spending time with my daughter, keeping the house (at least sort of but not really) clean, answering emails.... the list is endless. Tonight, I dragged myself through a kitchen cleaning effort and am now spending fifteen precious minutes at the computer, but am guiltily leaving a pile of bills for another day. Every minute is a minute less of sleep before I have to get up at 5am. Things are in perpetual chaos. I also suffer from chronic hip pain that I haven't had time to really address -- to heal I would need to exercise at least 3-4 times per week, spend time relaxing, doing acupuncture, etc. Instead, I work through pain every single day and just hope that my body outlasts my student loan payments. So I agree with you -- I don't know what the solution is. But since I chose to become a doctor, I at least want to feel like I'm learning to be good at it! Being responsible for people's lives is scary and stressful, but also amazing, so maybe there will always be a dichotomy in the lived experience of being a doctor -- the good and the bad. Good luck on all fronts!

I went through residency just when the new 16 hour restrictions were beginning. I did 24 hour shifts as an intern, but the classes that followed me did not. I agree that the idea behind the new system was good, but it is fatally flawed. I did an OB residency and I am now an MFM fellow. The new shift work system is taking significant OR time away from surgical training and residents are suffering. I see it everyday. They are also working horrible shifts...including what my interns call the suicide mission where they work tuesday-sunday nights with only monday night off. Interns who have children rarely see them and those who have spouses/significant others struggle to keep their relationships afloat. I believe that a system of checks and balances to prevent medical errors and more staffing in hospitals including PAs and NPs are a better solution.

The suicide mission indeed! I like that term -- that's exactly how it feels to work six nights in a row. I know several surgery residents and they stay post-call in the afternoon to scrub in to cases because it is their only time in the OR. Which just goes to show that medical trainees are eager, desperate even, to learn, even at the expense of time with loved ones. We all signed on for the sacrifice, but not if there isn't learning associated with it!

Completely agree! The weird intern schedule is brutal and dizzying from what I observe. Also, one of the main drawbacks I notice is that when residents transition to 2nd year they are completely unaccustomed to the long call and now responsible for sicker patients. Makes more sense to me to get accustomed to call when you have less responsibility as opposed to more.

Totally agree -- the right time to get comfortable with long hours and responsibility is intern year when there is a senior at your side and your patients are more garden variety. Until one month ago, a senior was checking my tylenol orders for children with cellulitis who could probably be managed outpatient, now I'm responsible for sixteen premature babies many of whom are on ventilators and some of whom are in danger of dying at any moment and I'm alone overnight with a fellow who is covering ninety babies. It's a strange way to structure things.

while I only had the 80 hour work rule, I had to work some shifts during my internship to keep below 80 hours. And as a result, my cardiology rotation was done in much the same way as you describe. What was supposed to be one of the high lights of my internship (I trained at one of the top hospitals for cardiology) became a jumble of H&Ps and sign outs. I was upset and felt cheated by the end of that rotation--I had been really looking forward to it. I do think we are cheating our young doctors out of a good experience. I think a 24 hour rotation would lend to more of a learning environment.

As an intern I am living the sign out jumble right now. There is never enough time to see all my patients, write up all the H&Ps and actually look anything up or take the time to read in a 12 hour day. We got rid of morning report in order to add some time to the day but that is just another lost learning opportunity... It is a sad state of affairs. I know my upper levels are working hard on their 30 hour calls but I'm always a little jealous that they know the census when I'm going through sign out twice a day and am just trying to keep all the new admits straight. I think you are absolutely right and these are the perils of duty hour restrictions.... What a wonderful, thought provoking post.

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In response I expect you to give a link back to one of my endorser who helps me to continue my passion and serve individual sites and blogs like yours.

am i the lone dissenter? i'm an internal medicine resident at a top-tier program that is also known for being humane. we adhere to work hours and we've actually shifted to day/night shifts for both interns and residents, so there's no abrupt transition between PGY-1 and PGY-2 year. we are still q4 on some rotations, so there are long call days and shorter days - and i really appreciate getting to see my son on the shorter days - but we never have to stay overnight, and i appreciate that too.

somehow, signout does not take that much time - when i was an intern, i spent less than half an hour a day updating signout and about 15 minutes giving signout. passoffs are going to happen regardless of the schedule, so everyone has to learn to do them well and efficiently.

we did have q4 overnight call when i was a med student, and those were some of the darker days of my life (other than when my son was a newborn!). some people are able to tolerate sleep deprivation and wacky sleep cycles more than others, and i would not be able to do it throughout residency, especially as i am expecting another baby.

i think that in either system, it is hard to do much learning as an intern - you're constantly running around answering pages or doing paperwork. as a resident, you have more time to learn, and subsequently, to teach. i've found that in my second year of residency, i get to sit and think about patients, i have to make the decisions on rounds, and i have to lead my team. thus, a lot of clinical growth happens despite not having 30-hour shifts, and i'm happy about that.

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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